Tag Archives: omega-3 lipid emulsions

Omega-3 Fatty Acids, Lipid Emulsions, and Hepatic Pathology

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Many have advocated for the use of parenteral fish oil lipids like Omegaven which are rich in omega-3 polyunsaturated fatty acids (O3FAs), though the data in support of them are limited (New lipid emulsions — lacking data to support usage …).

A recent study (J Pediatr 2014; 165: 59-64) identified seven liver-inclusive intestinal transplants who had received O3FAs.   This retrospective review study took place between 2003-2012.  These seven patients had received O3FAs for a mean of 62% of their total life span before transplant.  While these patients almost all had resolution of cholestasis (mean total bilirubin 0.7 mg/dL at time of transplant), advanced fibrosis (stage 3 or 4) was noted on explant pathology.  The histologic inflammatory scores were lower (P=.056) in comparison to O6FA group.

The authors make several important points:

  • The “results provide additional evidence that the improvement in hyperbilirubinemia following O3FA substitution therapy does not consistently produce histologic recovery of the liver.”
  • This study does not address whether comparable improvements could have been obtained from lipid restriction among the O6FA group.
  • Only 1 of 20 studies of O3FA lipid emulsion in PNALD includes hepatic histopathology as an outcome measure.

This is not the first study that indicates that liver fibrosis may persist and progress on O3FA therapy (J Pediatr 2010; 156: 327-31, J Pediatr Surg 2010; 45: 95-9, JPGN 2013; 56: 364-9).

Bottomline: Continued investigation of O3FA emulsions in PNALD is needed and assessing liver histology may be needed prior to intestinal transplantation.

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Parenteral Omega-3 Lipid Emulsions and Risk of Bleeding

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A recent study indicates that patient’s placed on omega-3 lipid emulsions (eg. Omegaven) may be at risk for bleeding due to platelet dysfunction (J Pediatr 2014; 164: 652-4).

While omega-3 lipid emulsions have received a lot of attention due to improvements in intestinal failure associated liver disease (IFALD) (see previous links to prior posts below), the amount of data supporting their usage and potential advantages compared with standard lipids at similar dosing remains limited.

This case report describes a 9-month old who developed life-threatening hemorrhage following a standard central line placement.  Due to difficulty stopping the bleeding, the patient’s omegaven was discontinued.  Standard workup for bleeding disorders were negative.  Subsequently, the authors investigated clot formation and platelet function in a neonatal animal model.

Key Result: Piglets treated with omegaven had a doubling of time to clot formation and marked platelet agonist inhibition.

The discussion notes that “there is an acknowledged risk of high dose O3FA lipids [omegaven] increasing bleeding time because of competitive inhibition of AA [arachidonic acid] production, hence decreased TxA2 [thromboxane A2].  In addition, platelet-derived growth factor-like protein and endothelial platelet activation factor are decreased.”

Take home points (from the authors):

  • “the case report and piglet studies together demonstrate that there is potential for a significant antiplatelet effect and inhibition of the coagulation cascade with O3FA therapy…”
  • “We would suggest discontinuation of Omegaven therapy 72 hours preoperatively in high-risk cases where bleeding may be difficult to directly control.”
  • “Institutionally, we have abandoned the sole use of Omegaven therapy.”

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